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The recent report based on data from the Minnesota State High School League (MSHSL) is deserving of additional comment. Lawless (1) and Roberts and Stovitz (2) suggest that the incidence of sudden cardiac death is far lower than that reported elsewhere, and, therefore, additional electrocardiographic screening is unwarranted and would produce little added value. That this evaluation was accomplished with the same database as has been previously queried by others with different results and is at variance with other reports is no surprise given the methods (3–5).

Unfortunately, the 4 “during participation deaths” over 20 years of study do not include athletes successfully resuscitated (n = 8) or not involved in sports participation at the time of sudden death (n = 7) or those whose deaths were not reported to the League or insurers. In this study, there were no less than 19 sudden death episodes recorded, the majority of which occurred outside the few hours per week of sports exposure. No data are available as to the sudden death episodes that would not have been captured by this database, such as the number of unexplained or sudden deaths or successful resuscitations in this population in Minnesota during the same time period. Thus, the numerator in the calculation of incidence of cardiac death in high school athletes may be severely underestimated. Likewise, the denominator is overestimated by applying it to all students rather than screened athletes, and the number of athlete-years is an estimate (approved participation in a sport does not mean that participation in that sport actually took place). As a result, estimates of the incidence of sudden death in this population are markedly understated, and any conclusions regarding the value of an electrocardiogram are speculative at best.

In refining the pre-participation evaluation, we must consider that its purpose is to prevent sudden death in athletes in whom a long and relatively healthy life could otherwise be anticipated and to afford those at risk appropriate evaluation and therapy. The goal is not merely to prevent sudden death on the field but sudden death at any time. A small percentage of adolescents die each year with hearts that could support them for many years if they could have been treated through the acute period of compromise (6). Preventing the loss of decades of life should stimulate creation of a registry in which all pertinent data are recorded. Such a database should include outcomes of screening (e.g., reasons for failure, recommendations, and outcomes) and permit us to further improve the health of our young citizens. Reliance on National Collegiate Athletic Association databases, public media reports, and catastrophic insurance claims is inadequate.

We need to determine whether we can further reduce the risk of sudden death in adolescents. If indeed a reduction of such deaths by virtue of better screening techniques and availability of automated external devices has occurred, it should be shown in appropriate evaluation of the data. It does appear from the Minnesota experience that we have improved our care sufficiently to report more resuscitations than deaths on the field and that screening may have provided the impetus for further evaluation and treatment in those at risk.

American College of Cardiology Foundation

References

(2013) Minnesota High School athletes 1993–2012: evidence that American screening strategies and sideline preparedness are associated with very low rates of sudden cardiac deaths. J Am Coll Cardiol62:1302–1303.

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